Repeated rejection in PACES has led me to recall events from my life that were better left forgotten. Of late, my mind has developed this dangerous tendency to create a mental picture of my examiners and try to understand their antagonism by forming nefarious, nebulous connections. So the Consultant who made me forget my neurological diagnoses resembles an orthopaedic surgeon who told me at the start of my postgraduate training that there would be no place for palliative medicine in the Corporate setting. Or that the Consultant in a corporate setting who has become a specialist by affiliating himself with an individual (whose specialist credentials are questionable) resembles a colleague who was branded an agreeable failure. Searching for reasons behind the disagreeable attitude of an army of examiners to my communication skills has led me down this rabbit hole searching for meaning. How can a seemingly innocuous, moderately unsuccessful person who is used to truth-telling antagonize an army of corporate doctors?

Postgraduate training in Palliative medicine is beset with numerous challenges, not least being the mislabelling of a trainee as an impostor or, better still, an academic outcast (by the corporate gaze). While the voice in your head might label you repeatedly as an impostor for not doing much (or not doing anything at all), the ideological challenge of opening palliative medicine training to those not trained in Internal medicine is perhaps the biggest and most unkind (but perhaps easily foreseeable) obstacle that the trainee is bound to come face to face with (on a more than regular basis). A good specialist is expected to recognize that competent Palliative care might not be possible unless medical issues facing the patient have been recognized and managed. It might be considered a given that ignoring medical issues in favour of an ideological obligation risks causing serious harm. Issues such as opioid induced respiratory depression, the potential adverse impact of opioids on survival, and risks of prescribing a combination of CNS depressant medications are other issues that the trainee needs to be encouraged to handle.

There is a risk that truth-telling and allegiance to an ethical obligation may be considered inimical to the conventional construct of a modern hospital. How far is the system willing to go to tell the patients that their near and dear ones may be dying and that we only have a handful of options remaining and that there has been a tectonic shift in our goals of care (which have moved away from focusing on survival as the preferred outcome to quality of life, a rather ephemeral poorly defined construct which might be difficult to define). Or, for that matter, how do you make the old garrulous and senior administrative official (who has been well accustomed to clearing his throat and putting forward the excuse of an overburdened system to justify lack of patient safety) understand this shift in preferred outcomes? Who do you call for help the next time that you are made to acknowledge the dispensable nature of your work? Perhaps, these thoughts will resonate a little more the next time that you are forced to work with a resident who might be too busy eating at a corporate sponsored lunch to give you a respectable referral, or a colleague who might cast aspersions on the patient who did not seem to be too comfortable before dying (is death supposed to be comfortable) and tells you to keep your patients separately in a bed (allotted at a safe distance from their supportive care patients), or another resident who when reprimanded informs you that they have not being trained to reach that level as yet. Or for that matter, an administration that wipes your entire department off the slate (to them, palliative medicine does not exist as an independent specialty).

Facing criticism for engaging with medical issues that other so-called specialists might not be vigilant about might result in yours truly being branded as a Specialist who is more interested in retracing his footsteps (and an allegation of wanting to repeat his postgraduate training in a different specialty, Groundhog Day style).

I have come to the taxing realization that those who raise their voice against a lack of postgraduate beds during training, highlight a lack of allegiance of academic organizations imparting so-called specialist training to palliation themselves, voice their exclusion from due consideration for faculty positions (which were gifted to their juniors who chose to keep their mouths taped) should be prepared for charting their own circuitous and circumlocutious course in life.

Focusing on your patients and their families’ concerns might then prove to be key. Sometimes in the distant but recognizable echo of a poor patient’s voice who is teary because he is too overwhelmed to express gratitude or in the shared camaraderie with a patient (who least expected to survive her web of medical issues and comorbidities, but is still alive) you might find a slight vestige of meaning.

originally published by the author on medium on july 29, 2025 (available at https://medium.com/@xerxes85/is-specialist-palliation-the-albatross-around-my-neck-and-the-reason-for-my-futile-feeble-attempts-2b36481abf74).

Disclaimer – Every attempt has been made to safeguard the identity of patients referred to in the vignettes and any circumstances arising out of this moral treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s reputation and has tried his level best to ensure that identities are fiercely protected.